It is common for training surgeons to perform their first phacoemulsification cases in uncomplicated cataract patients under supervision of an experienced surgeon. The operating time during a training case is significantly longer than for an experienced surgeon, but rarely is the outcome inferior—as long as the trainee follows the surgical plan. In most instances, the operation runs smoothly; however, to sit beside your student as he encounters a vision-threatening complication is an unpleasant experience, especially when local anesthesia is used and the patient can hear the conversation in the operating theater. In this article, I will describe one case where a complication arose while a training surgeon tried his hand at phacoemulsification.
CASE PRESENTATION
A 75-year-old woman had uneventful cataract surgery in her left eye a couple of years ago, and her postoperative UCVA was 1.0. Recently, she returned to our office for cataract surgery in her right eye. In this eye, her low visual acuity (0.3) was fully attributable to a moderately dense nuclear sclerosis.
Apart from the cataract, the eye was normal—she had a clear cornea, the pupil was dilating well, and no pseudoexfoliation was present—and therefore her case was suitable for a training surgeon to attempt under the surveillance of a senior colleague. On the day of the operation, we informed the patient that a training surgeon would perform the cataract surgery and assured her that at the first sign of any apparent difficulty, an experienced surgeon would immediately take over. She and her son agreed.
The training surgeon had an uncomplicated start; however, he created two radial tears at the 1- and 6-o'clock positions during capsulorrhexis formation.
HOW WOULD YOU PROCEED?
Radial tears in the anterior capsule mandate caution when proceeding because the tear may easily extend across the equator of the lens and into the posterior capsule. Possible developments of the situation may include (1) virtually normal progression of phacoemulsification, (2) posterior capsule rupture with vitreous prolapse, necessitating anterior vitrectomy, or (3) a portion of or the entire lens dropping posteriorly into the vitreous cavity, demanding a pars plana posterior vitrectomy procedure.
Likewise, IOL fixation can vary. Careful placement within the capsular bag is possible provided the tears have not extended posteriorly. In case of limited damage to the posterior capsule, the surgeon can place the haptics of a three-piece IOL into the ciliary sulcus or in front of the anterior capsule with the optic nudged behind the rim of the incomplete capsulorrhexis. If the eye is left aphakic after the primary procedure, a scleral-fixated IOL can be implanted during or after the primary surgery.
Although anterior chamber IOLs are used more infrequently now than in the past, the modern designs are gentle to both chamber angle and endothelium, and there is no risk of hemorrhage or late dislocation. Therefore, anterior chamber IOLs should not be ruled out as an alternative solution when capsular support is lost.
If this were your patient, how would you proceed?
HOW I PROCEEDED
I intervened and proceeded as follows: First, I widened the capsulorrhexis nasally and after careful hydrodissection and hydrodelineation, I emulsified and removed the lens. A subincisional cortical cleanup technique was used where the broad anterior capsular flap was in the way. I filled the anterior chamber and the capsule with an ophthalmic viscosurgical device (OVD); however, I noticed a posterior capsular break and proceeded with anterior vitrectomy. Afterward, it appeared that the anterior capsule flaps were intact enough to cross-fixate a four-haptic IOL (Akreos Adapt AO; Bausch & Lomb, Rochester, New York) with two haptics. The incision was slightly widened during implantation and fixation of the IOL, and I then closed it with one cross-stitch 10-0 nylon suture. An intracameral antibiotic injection concluded the procedure, which took 1 hour.
FOLLOW-UP
We provided the patient with continuous information about the progress of the surgery. She was aware that a complication had made the surgery more demanding and time consuming, but we also informed her that the surgical goals, removing the cataract and placing an IOL, were reached. After the procedure was completed, the surgical information was repeated; we also relayed the news to her son, who had accompanied her to the hospital. An extra follow-up visit was planned for the next day.
First postoperative day. The patient achieved somewhat clear vision immediately after surgery. Visual acuity in her right eye was 0.2 (-1.00 -1.50 X 80) and 1.0 in her left. In her right eye, the intraocular pressure (IOP) was 26 mm Hg, and she had slight corneal edema with stromal haze and small folds in Descemet's membrane centrally. A few endothelial cells were seen in the anterior chamber. Her pupil was slightly dilated, regular, and round. We prescribed dexamethasone three times daily. On the second day postoperative, the patient's vision cleared.
Seventh postoperative day. One week later, visual acuity was 0.4 in her right eye (-0.50 -1.75 X 100) and 1.0 in her left. IOP dropped to 16 mm Hg in the right eye. Additionally, she presented with a clear cornea, a couple of endothelial cells in anterior chamber, and a centered pupil with two vitreous strands stretching from the pupillary border temporally to the inside of the tunnel incision. The IOL remained securely in place. We tapered the dexamethason after 3 weeks postoperatively.
WHAT HAVE I LEARNED FROM THIS CASE?
This case is not only about surgical maneuvers; it also highlights how to manage potential problems when training new surgeons in phacoemulsification. Approximately 15 to 20 years ago, residents performed eyelid surgery and strabismus surgery under surveillance before proceeding with intraocular operations. In more recent years, residents now start their training with intraocular microsurgery and have less experience with extraocular ophthalmic surgery. Wet lab courses in basic phacoemulsification techniques are compulsory before attempting live surgery in patients.
In our clinic, surgical training starts with sutures in animal eyes under a laboratory microscope. In the beginning, the training surgeon carries out only single stages of the operation, often starting backward (eg, evacuation of OVD by irrigation/aspiration after IOL placement) and adding successive stages as the surgeon gains skill and dexterity.
Because general anesthesia is used infrequently today, properly informing the patient that a training surgeon will be performing the operation is delicate. In my experience, it is uncommon for a patient to refuse the training surgeon to proceed under the surveillance of an experienced senior colleague; however, I have often heard comments afterward, such as "I felt some discomfort during surgery," or "This operation took quite some time, didn't it?"
We must be aware of the problems we face when undertaking the task of educating new surgeons. When choosing patients for the beginner surgeon, one basic consideration is to exclude eyes at risk for complications, such as deep-set eyes, patients who squeeze their eyes at preoperative examination, submaximal pupil dilatation, and dense cataracts.
Before allowing the trainee to perform surgery, the patient should accept the plan with complete informed consent, including the expectedly prolonged operation time. Optimally, the patient should meet the training surgeon when the cataract diagnosis is made and immediately receive information about the plan for the training surgeon to operate. Previously healthy eyes with light to moderate cataract (nuclear sclerosis, cortical cataract, or posterior subcapsular cataracts) are suitable candidates.
One new tool for training residents is the computerized phacoemulsification simulator, which is currently under evaluation in several international centers. My bottom line for training new surgeons is that patient selection is vital to minimize the risk for complications. Informed consent is also paramount. In case a complication demands further control, visits, or operations—and especially if the end result is less than would have been expected from a routine surgery—a badly informed patient is certainly more prone to raise significant problems (which might include legal actions) than a patient who has accepted the plan after thorough information.
Björn Johansson, MD, PhD, practices in the Department of Ophthalmology, Linköping University Hospital, Sweden. Dr. Johansson states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: Bjorn.Johansson@lio.se.
